Individual
DR. DAVID A THEODORO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
12255 DE PAUL DR NORTH BLDG, STE 260, BRIDGETON, MO 63044
(314) 647-8269
(314) 646-1700
Mailing address
PO BOX 23666, JACKSON, MS 39225-3666
(601) 200-2780
(601) 200-2788
Taxonomy
Speciality
Code
Description
License number
State
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
036095641
IL
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
118293
MO
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
Primary
28104
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036056372
SUBSTANCE CONTROL
IL
05
—
036095641
—
IL
05
—
0360957641
—
MO
01
—
1102596
BNDD
MO
01
—
118293
LICENSE
MO
Enumeration date
06/20/2005
Last updated
08/27/2020
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